320. ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA

Abstract Background Patients with sigmoid shape have an advanced form of the disease and are considered the most difficult to treat. A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia. Methods From 1995–2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study. Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3, or the need for retreatment. Results Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD. The surgical procedures were completed laparoscopically in all patients. During follow-up, two patients (2.1%) developed squamous cell carcinoma (SCC), both in the CLHD group. All patients in both groups had an improvement in their Eckardt score after surgery, and the failure rates were 27.6% (16/58) after CLHD and 5.9% (2/34) after PDLHD (p < 0.01). Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH, and in 6 after CLHD (p = n.s.). Conclusions Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients.